Other·February 23, 2023

Health and Safety Code 1418.91 (a) and (b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On November 29, 2022, at 10 a.m., an onsite visit to the facility was conducted to investigate an allegation of sexual abuse. It was determined that based on interview and record review, the facility failed to report an allegation of sexual abuse to the State Survey Agency (SSA) within 24 hours. The facility was made aware of the alleged sexual abuse on Patient 1on November 26, 2022, and did not report the allegation to the SSA until November 28, 2022 (Approximately 39 hrs. after the facility was made aware of the allegation). This failure increased the risk for further abuse due to delayed notification to respond and advocate on behalf of Patient 1. A review of the report received by the Department from the facility on November 28, 2022, indicated Patient 1's family member alleged that the patient was sexually abused by a staff member on November 26, 2022. During the onsite visit, Patient 1's record was reviewed. Patient 1 was admitted to the facility on November 17, 2022, status post (S/P) hospitalization for treatment and management of sepsis (life threatening illness caused by your body's response to an infection), dementia (condition characterized by impairment of at least two brain function, such as memory loss and judgement), and psychotic disorder (mental disorder characterized by a disconnection from reality). On November 29, 2022, at 10:22 a.m., Director of Nursing (DON) 1 and the Minimum Data Set (MDS- an assessment tool) Coordinator were interviewed. DON 1 stated that on November 26, 2022, at 8:38 p.m., Patient 1's family member visited and approached the nurse stating the patient (Patient 1) was raped the night before by the nurse and a couple of nights before Thanksgiving Day. DON 1 stated the family member reported that the patient was raped twice. DON 1 and the MDS Coordinator stated Patient 1 refused body check even in the presence of the police and was too confused to give details. A review of Patient 1's progress notes dated November 26, 2022, indicated, "At around 8:38 p.m., the (relation of the family member to Patient 1), (name of the family member) approached the nurse in the station and reported/stated 'My (Patient 1) was raped lastnight (sic) by the nurse and a couple of nights before Thanksgiving (Day). As per the (family member), the resident (Patient 1) was raped 2x...'" On December 27, 2022, at 10:33 a.m., during an interview, the Registered Nurse Supervisor (RNS) stated that an allegation of abuse should be reported immediately or within 2 hours to the SSA. The RNS further stated that if not reported on time, the state will not be able to advocate for the patient on a timely manner. On December 27, 2022, at 10:39 a.m., DON 2 was interviewed. DON 2 stated reporting should be done as soon as possible or within 2 hours because the State had to advocate for the patient. DON 2 further stated, if not reported early, there could be a discrepancy with the time frame of the investigation which could result in patient harm. A review of the facility's policy titled, "Abuse Investigation and Reporting," dated May 28, 2019, indicated, "Policy: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported...Reporting...2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury..." Based on interview and record review, the facility failed to report an allegation of sexual abuse to the SSA within 24 hours. The facility was made aware of the alleged sexual abuse on Patient 1, on November 26, 2022, and did not report the allegation to the SSA until November 28, 2022 (Approximately 39 hrs. after the facility was made aware of the allegation). This failure increased the risk for further abuse due to delayed notification to respond and advocate on behalf of Patient 1. This violation had an immediate relationship to the health, safety, and security of Patient 1.